Article Text

Association of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control study
  1. Lion Shahab1,2,
  2. Emma Beard1,2,
  3. Jamie Brown1,2
  1. 1 Department of Behavioural Science and Health, University College London, London, UK
  2. 2 SPECTRUM Consortium, UK – Shaping Public Health Policies To Reduce Inequalities and Harm, UK
  1. Correspondence to Dr Lion Shahab, Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK; lion.shahab{at}


Introduction This study assessed whether initiating e-cigarette use increases the uptake of cigarette smoking in US adolescents compared with behavioural and synthetic controls.

Methods Data come from 78 265 adolescents in the National Youth Tobacco Survey (2014–2017) of whom 38 630 provided information about the first tobacco product they had used in 2014/15. Ever, past 30 day and established (30 day use and 100+ lifetime cigarettes) cigarette smoking was compared in adolescents who first used an e-cigarette (exposure group), a non-cigarette combustible (CT) or other non-combustible tobacco (NT) product (behavioural controls), and propensity score matched adolescents without initial e-cigarette use (synthetic controls).

Results Relative to behavioural controls, adolescents who tried e-cigarettes first were less likely to have ever smoked cigarettes (26% vs CT (42.4%; OR 0.48, 95% CI 0.40 to 0.57), or NT initiators (52.7%; OR 0.32, 95% CI 0.26 to 0.39)), to be past 30 day (6% vs CT (11.9%; OR 0.48, 95% CI 0.36 to 0.62), or NT initiators (20.0%; OR 0.26, 95% CI 0.19 to 0.35)) or be established cigarette smokers (0.7% vs CT (3.9%; OR 0.17, 95% CI 0.10 to 0.30), or NT initiators (8.4%; OR 0.08, 95% CI 0.04 to 0.13)). E-cigarette initiators were also less likely than synthetic controls (without initial e-cigarette use) to have ever smoked cigarettes (OR 0.76, 95% CI 0.62 to 0.93), be past 30 day (OR 0.71, 95% CI 0.55 to 0.91) or be established cigarette smokers (OR 0.26, 95% CI 0.13 to 0.51).

Conclusion Less than 1% of US adolescents who use e-cigarettes first were established cigarette smokers. They were less likely to be smokers than adolescents who tried other combustible or non-combustible tobacco products first and propensity score matched adolescents without initial e-cigarette use.

  • electronic nicotine delivery devices
  • harm reduction
  • priority/special populations
  • non-cigarette tobacco products

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors LS conceived the original idea for this study. LS and JB obtained funding. LS wrote the initial draft with further input from EB and JB. LS is guarantor for this article. All authors read, reviewed and approved the final version. All researchers listed as authors are independent from the funders and all final decisions about the research were taken without constraint by the investigators. LS had final responsibility for the decision to submit for publication.

  • Funding This project is funded by Cancer Research UK (C1417/A22962). All authors are members of the UK Centre for Tobacco and Alcohol Studies (UKCTAS), funded under the auspices of the UK Clinical Research Collaboration (MR/K023195/1).

  • Competing interests LS has received a research grant and honoraria for a talk and travel expenses from manufacturers of smoking cessation medications (Pfizer and Johnson & Johnson). JB has received unrestricted research funding from Pfizer to study smoking cessation.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. The data are freely available from